Reducing Risks for Mental Disorders Frontiers for Preventive Intervention Research (1994) / Chapter Skim
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7 ILLUSTRATIVE PREVENTIVE INTERVENTION RESEARCH PROGRAMS
7 ILLUSTRATIVE PREVENTIVE INTERVENTION RESEARCH PROGRAMS
Pages 215-314
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From page 215... ...
This review of preventive interventions is based on three principles presented in earlier chapters in this report: (1) Prevention of the initial onset of mental disorders can be accomplished through intervention programs aimed at risk reduction, which can include both reduction of causal risk factors and enhancement of protective factors.
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Many of the prevention programs that were reviewed used quasiexperimental designs. Where their findings provide some confirmatory evidence for a study with a randomized controlled trial design, or where their findings provide new leads in areas where there have been no randomized controlled studies, the information is briefly discussed in the chapter.
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From page 217... ...
Furthermore, the accumulation of data about well-documented risk and protective factors is essential to the design of preventive interventions, and the identification of malleable, or modifiable, risk factors is crucial to the success of prevention efforts built on the risk reduction model. In identifying risk and protective factors, the causal status of the risk or protective factor is crucial.
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Farther along the chain, at ages 9 to 11, academic difficulties also begin to stabilize as predictors of later conduct disorder and substance abuse. At this point the academic problems are not just a general risk factor for multiple disorders; they are also a precursor symptom for conduct disorder and can also be used to target an indicated population.
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Finally, because of potential effects on outcomes, there should be a description of the recruitment process and the consent process. Description of the Intervention Program All too often, treatment interventions as well as preventive interventions lack adequate description.
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DescAp~don of We Research Methodologies The choice of research methodologies is a major issue in examining preventive interventions and the research trials designed to determine their outcomes. It heavily determines whether evidence is compelling that a preventive intervention could have produced its intended effect.
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Without at least preliminary evidence that the intervention was successful in reducing risk factors or increasing protective factors, or in showing that protective factors reduced the strength of the relationship between risk factors and outcomes or affected some hypothesized mediating process, the claim that the intervention had an effect on some aspect of the causal chain leading to disorder becomes less .
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From page 223... ...
INTERVENTIONS FOR INFANTS In infancy, the biopsychosocial risk factors that can hinder development include, but are not limited to, preventable infections, disease, or injuries that can cause brain damage, neurodevelopmental disorders, or behavioral disorders; problems of parent-infant attachment or parenting; deprivation of cognitive and language stimulation; economic deprivation; and child maltreatment. The corresponding protective factors of robust health and "good-enough" parenting-coupled with adequate nutrition and shelter-encourage the physical, intellectual, and emotional growth of the child.
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224 I Reducing Risks for Mental Disorders Social Fields Being Born Healthy and at Normal Birthweight~ Dying Major Life Changes and Stages of Developmental Tasks Life Acquiring language skills ~ infancy end Developing impulse control JO Early Childhood Entering school J Learning to read and write - l Middle Developing social skills r>Childhood Entering puberty ~ Dating l Developing independence I Leaving home I.: Pursuinghigher education Choosing a vocation Marrying Giving birth Parenting a young child Parenting an elementary age child Parenting a pubescent child Achieving career success Parenting a child who is leaving home Parenting a newly married offspring Providing care for an ill parent Becoming a grandparent Retiring from a job Coping with illness Providing care for an ill spouse Coping with the death of a spouse Coping with the death of peers yAdoBescence Early Adulthood middle Age Devoid Age FIGURE 7.2 Developmental tasks and social fields for preventive interventions over the life course. Source: Adapted from Kellam, S
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Well-established medical guidelines define the timing and protocol for appropriate prenatal care, but frequently these are not followed for these high-risk groups (IOM, 1985~. Lack of prenatal care has important implications for mental disorders.
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A significant finding was that casefinding and social support are the most effective means of increasing early and continuing use of prenatal care and compliance with health recommendations among mothers most at risk of absent or inadequate prenatal care (IOM, 1988~. Immunizatiotl Childhood immunization, like prenatal care, is an example of a universal preventive intervention directed at the entire population even though it is given to individuals.
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to protect children from meningitis, and hepatitis B For example, when children are not immunized for Hib and meningitis occurs, there is the possibility of long-term negative effects on the brain, resulting in neurodevelopmental problems, mental retardation, learning disability, and psychological and behavioral disorders (Plotkin and Mortimer, 1988~.
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Programs Aimed at Improving Parenting alla Reducing Risks for Infants In addition to the universal, widely implemented programs just discussed, there are some specific, experimentally designed preventive interventions targeted at infants and their families.
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The nurse-visited mothers experienced greater social support, improved their diets more, and reduced their cigarette smoking. The greatest impact on infant's birthweight and mother's length of pregnancy was for nurse-visited young teenagers.
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The selective preventive intervention, which consisted of home visits by a two-person team a trained interventionist and a teenage African-American work study student aimed to prevent developmental delays in the infants by teaching mothers about caretaking practices and enhancing parent-infant interactions. At four months, the infants who had been randomly assigned to the intervention group had significantly better weight and length and higher scores on the Denver Developmental Screening test.
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. Within each weight group, one third of the subjects were randomly assigned to an experimental group, and two thirds to a control group.
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At kindergarten entry, 96 of the original 111 subjects were randomly assigned again to school-age experimental and control conditions, which continued for three years. This design allowed comparison of the effects of early versus late versus combined intervention on children's cognitive and social development.
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An Example from Prevention Services Healthy Start in Hawaii, a selective intervention program for families at risk of child abuse, is similar in concept and content to the Prenatal/Early Infancy Project described above. Healthy Start, however, was initiated by the Maternal and Child Health Branch of the Hawaii Health Depart
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From page 240... ...
quality child care in infancy and early childhood; (3) parental competence and promotion of child development through parent education, infant stimulation, home visitors, and social support; (4)
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Recent preschool preventive interventions have addressed several risk factors that are related to these developmental tasks, as well as to the development of mental and behavior problems. Risk factors and precursor symptoms that have been addressed in promising interventions during childhood include economic deprivation, poor family management practices, cognitive or developmental delays, school failure, and early behavior problems.
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From page 242... ...
Eligible volunteers recruited from door-to-door surveys were randomly assigned to experimental or control conditions. The two-year selective preventive intervention included 20 to 30 home visits of 1~/2 hours duration during the first year, which focused on mother-child interaction, recognized the child's developmental status, and used the home as an environment for learning.
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The selective preventive intervention design involved trained home visitors (either paid paraprofessionals or unpaid volunteers) , who visited mothers and their children twice per week for 30 minutes when the child was aged two to four.
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Parent-child interaction has also been targeted during early childhood through indicated preventive interventions. Strayhorn and Weidman (1991)
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The selective preventive intervention, begun in 1962, consisted of daily participation in preschool over a one- to two-year period and weekly home visits by trained teachers. The experimental intervention was associated with positive effects on academic performance and social adjustment when randomly assigned experimental and control subjects were followed up and compared at age 19 (Berrueta-Clement, Schweinhart, Barnett, Epstein, and Weikart, 1984~.
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Programs Aimed at Enhancing Social Competence The evidence linking aggression and other behavior problems in childhood with increased risk of later mental disorders has led to the development of educational strategies designed to enhance the social competence of youngsters. These interventions are based, in part, on the hypothesis that aggressive and disruptive children are deficient in basic, teachable, interpersonal skills (Spivack and Shure, 1974)
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From page 247... ...
The results suggest that providing a social competence curriculum to inner-city disadvantaged children before first grade can help to reduce aggressive and socially inappropriate behaviors predictive of later mental health problems. By the spring of kindergarten, only 30 percent of children in control classrooms were rated by their teachers as normally adjusted, compared with 77 to 85 percent of the children in the three experimental groups exposed to different lengths and combinations of intervention at ages four and five.
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From page 248... ...
There is also some evidence that multicomponent early childhood interventions have shown effects in promoting prosocial behavior and preventing behavior problems. · Preventive interventions designed to enhance social competence through teaching interpersonal problem-solving skills at ages four and five in urban day care and school settings and through parents training their children in these skills at home have produced durable effects on conduct problems in children.
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From page 249... ...
Highrisk factors for children, including early behavior problems, have been addressed through enhancement of social competence and academic achievement. Intensive family preservation services have provided crisis intervention for families where children are at risk for out-of-home placement.
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Reducing the risk of out-of-home placement might reduce the subsequent onset of mental disorders. The Homebuilders Program in Tacoma, Washington, pioneered the development of intensive family preservation services.
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Social competence components also have been included in interventions designed for populations selected for intervention because of exposure to specific risk factors or stressors during childhood, including parental divorce, parental substance abuse, and parental depression. Children from homes broken by marital discord are at risk for conduct disorder and substance abuse disorders (Baumrind, 1983; Penning and
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, in their Children of Divorce Intervention Program (CODIPJ, sought to reduce risk and enhance adaptation among children of divorce. They developed a curriculum of 10 one-hour weekly sessions for children in grades 4 through 6 whose parents had divorced.
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Longer-term effects of the intervention have not been investigated. The results to date suggest the promise of selective preventive interventions focusing on the enhancement of social competence during the elementary grades for children who have recently experienced parental separation.
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On short-term follow-up, the social skills training showed an overall positive effect on conversational skill acquisition and peer response. Lochman and co-workers tested an expanded social competence curriculum, the Asocial Relations Intervention Program, with a sample of 86 African-American fourth-grade children identified through sociometric ratings as the most socially rejected and physically aggressive in their classrooms and then randomly assigned to intervention and control groups (Lochman, Cole, Underwood, and Terry, in press)
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From page 255... ...
It combined home-based training for parents in family management skills, offered once every two weeks for a two-year period, with social skills training delivered in schools to disruptive boys within small groups of prosocial male peers. Parents received an average of 17 parenting sessions over the two-year period, and 19 training sessions were provided to the children over the same time.
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From page 256... ...
Learning and achievement problems have also been addressed in tandem with peer rejection through selective interventions targeted at children with both risk factors. Individual tutoring has been shown to produce significant improvements in reading and math achievement
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The initial universal preventive intervention program lasted four years, from the first through the fourth grade. It was a multicomponent intervention and sought to reduce risks in family, school, and peer environments.
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reported positive gains in student academic achievement and in standardized reading and math tests compared with national norms over a 12-year period after implementation of the program. A follow-up study of children from intervention schools and a matched comparison group found higher reading and math scores, school grades, and social competence scores among the children in the intervention schools (sauce, Comer, and Schwartz, 1987~.
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From page 259... ...
, and programs offered through Boys and GirIs Clubs in public housing (Schinke, Orlandi, and Cole, 1992~. Nonexperimental results suggest that providing well-designed opportunities for active learning and practice of cognitive, interpersonal, and problemsolving skills to children from economically deprived backgrounds during late childhood and early adolescence in after-school programs might contribute to the development of social competence and reduce behavior problems.
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From page 260... ...
Unfortunately, few studies have moved beyond short-term follow-ups of effects on risk factors for these disorders. · Because multiple risk factors have been implicated in the etiology of most, if not all individual disorders, including conduct disorder, substance abuse disorders, and mood disorders, investigators have designed multicomponent interventions focused on reducing risks in several domains (including family, school, and peer environments)
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From page 261... ...
Even though the co-morbidity of numerous disorders, including substance abuse, conduct, and mood disorders, has been well established (Elliott, Huizinga, and Menard, 1989; lessor and lessor, 1977) , the preponderance of research on preventive interventions for adolescents has been disorderspecific, focusing for the most part on the prevention of substance abuse, or to a lesser extent, on the prevention of conduct disorder.
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, in their study Changing Teaching Practices, conducted a selective preventive intervention research program in which seventh-grade students in three schools were randomly assigned to one of 15 experimental or 18 control classrooms. Teachers were also randomly assigned to experimental or control classrooms.
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From page 263... ...
To accomplish this goal, prevention researchers have tested school curricula focusing on enhancing social competence, providing social influence resistance training, and promoting norms against drug use. The risk factors addressed by these programs include the early age of onset, social influences to use drugs, including drug-using peers, and norms and attitudes favorable to alcohol or other drug use.
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From page 264... ...
The combination of social influence resistance and normative change content in school curricula has produced modest significant reductions during early adolescence in the onset and prevalence of cigarette smoking, alcohol, and marijuana use across a number of experimental studies conducted by a variety of investigators (Ellickson and Bell, 1990; Hansen et al., 1988; McAlister, Perry, Killen, Slinkard, and Maccoby, 1980; see Hansen, 1992, for a recent review.) Hansen and Graham (1991)
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From page 265... ...
have suggested that previously reported positive effects of peer resistance skilIs-training programs may have been due to the normative education components included in these programs. It appears that the enhancement of social norms against tobacco, alcohol, and marijuana use in adolescence is an essential component of school curricula seeking to prevent the early onset of alcohol and other drug use as a strategy for preventing substance abuse disorders.
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Although attention to the establishment of a clear consensus regarding norms is apparently an important component of substance abuse prevention programs, this strategy has some limitations and risks. For example, Ellickson and Bell (1990)
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Nevertheless, the results reported to date indicate multiple drug use behaviors were reduced by the combination of curriculum and mobilization of parents, community members, and the media to promote norms consistent with those provided in the curriculum. Policy Initiatives Substance abuse disorders depend on the availability of substances and on the prevalence of substance use in the population.
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Conversely, the work of Botvin and colleagues in substance abuse prevention has combined (1) training in skills to resist social influences to use drugs with (2)
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From page 269... ...
, and affect adult functioning and opportunities. Risk factors associated with the development and diagnosis of conduct disorder include early aggressive behavior, school failure, criminal and alcoholic behavior of parents, poor family management practices (e.g., inconsistent discipline, poor monitoring)
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Samples of seventh-grade students with low academic motivation, alienation from family, and several school discipline referrals were identified in a low-income urban school and a middle-income suburban school. Within schools, participants were placed in matched pairs on the basis of sixth-grade academic records and randomly assigned to receive the intervention or serve as controls.
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From page 271... ...
evaluated an intervention that included the establishment of an organizational structure to facilitate shared decision making and management in schools, the use of curriculum and specialists trained to respond to student concerns, academic innovations including cooperative learning, reading and test taking programs, and career exploration. In addition, direct services were provided to a randomly assigned subsample of high-risk students in participating schools.
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These results show the promise of interventions aimed at the risk factors associated with school transitions. They also suggest that throughout primary and secondary school, having a close relationship with a supportive teacher may be a signifi
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The intervention program was implemented as a nationwide campaign. The components of the program included (1)
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That is, the preventive interventions focus on changing norms regarding violent behavior and providing skills to solve problems without violence. Social competence promotion in problem solving and developmentally appropriate social interaction have been included in school-based curricula seeking to prevent violence.
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Few of these interventions have been evaluated for effects on conduct or other mental disorders, but a number have shown effects in reducing risk factors. Examples include efforts to promote broader academic success during adolescence.
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The following review of a number of prevention programs focuses on five major areas of adult life where preventive trials have reduced risk factors and enhanced protective factors in the course of adult development. These include programs aimed at (1)
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From page 277... ...
Enhancing Mantal Relationships Destructive marital conflict and marital distress are major risk factors for many forms of interpersonal and psychological dysfunction and psychopathology (Coie, Hawkins, Ramsey, and Watt, 1991~. Specifically, marital distress has been associated with higher rates of depression in adults and also related to the development of conduct disorder in children (see Chapter 6~.
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From page 278... ...
education and occupational problems, particularly for the female spouse in joining or rejoining the labor force. Bloom and Hodges developed the University of Colorado Separation and Divorce Program specifically to address these risk factors and to enhance protective factors (Bloom, Hodges, Kern, and McFaddin, 1985; Bloom,
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From page 279... ...
Below are two prevention programs that promise to reduce risks associated with insufficiently supported childbearing and childrearing.
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From page 280... ...
Personal Control (PPC) Preventive Intervention for a Caesarean Birth Population, a selective prevention program, to enable the CB mother to accomplish the specific psychological tasks associated with caesarean births and to enhance her coping skills so that she can ensure a positive outcome and deal successfully with any future caesarean births (Tadmor, Brandes, and Hofman, 1988; Tadmor and Brandes, 1984~.
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From page 281... ...
The program was evaluated in a randomized controlled trial. Mothers completed questionnaires on the fourth or fifth postpartum day, and there were follow-ups at 6 and 12 months after the caesarean birth to assess physiological and psychological recovery and to document the implementation of the intervention model, beneficial effects of the model, duration of full breast-feeding, and response to crises.
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From page 282... ...
Results of a randomized controlled trial evaluating the effect of the nurse visiting program on outcomes for the mothers showed reduction in a number of risk factors. Among women who had not graduated from high school when registered for the study, 59 percent of the nursevisited and 27 percent of the comparison group had either graduated or enrolled in an educational program by six months postpartum.
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From page 283... ...
The low levels of social support, high levels of burden and work demands, and inadequate material and informational resources for coping with the task of caregiving all constitute risk factors for psychological distress (Heaney, 1992~. The Caregiver Support Program was designed to train house managers and caregivers to cope more effectively in their stressful work environment.
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From page 284... ...
Such protective factors include the acquisition of effective job-seeking skills and strong social support during the job-seeking process. The JOBS Project for the Unemployed was a selective preventive intervention designed to help job losers cope with the stresses of job loss and setbacks in the job search process, as well as seek social support and develop and use job-searching skills leading to more rapid reemployment in high-quality jobs (Price, van Ryn, and Vinokur, 1992; Vinokur,
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From page 285... ...
The impact of the JOBS project was evaluated in a randomized controlled trial. Two and one-half years after the completion of the randomized trial, people in the experimental group showed significant reductions in depressive symptoms (Price et al., 1992~.
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Programs Aimed at Preventing Depressive Disorders Among Adults at Risk Because of Poverty and Minority Status Depressive disorders, referred to here as depression, are a major health problem (see Chapters 5 and 6~. Not only is depression one of the most common of the serious mental disorders, but, partly because of stigma and partly because of lack of knowledge regarding its symptoms and the availability of effective treatments, most persons who have the disorder do not receive treatment.
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From page 287... ...
Participants assigned to the experimental group showed the intended changes in the cognitions and behaviors hypothesized to be risk factors for depressive symptoms. Compared with the control group, those assigned to receive the depression prevention course became less pessimistic, had more positive (self-rewarding)
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From page 288... ...
In addition, most spoke only Spanish, and their social roles were limited to housekeeping. Counterbalancing protective factors could be mobilized, however.
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From page 289... ...
In addition, these results suggest that further analyses may reveal interesting and informative relationships between baseline depressive symptoms and preventive interventions. Program Ann ed at Supporting Adult Children Providing Care for Ill Parents The stressful role of caregiving has been reported to have negative effects on physical (Golodetz, Evans, Heinritz, and Gibson, 1969)
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From page 290... ...
The patterns of improvement did reflect, to some degree, the nature of the intervention. Peer-led groups spent more time socializing and sharing personal experiences and experienced higher levels of informal social support, whereas professional-led groups tended to focus more on highly structured skills and knowledge.
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From page 291... ...
The project demonstrates that randomized controlled trials with lowincome, public sector primary care populations are feasible, these trials may include non-English-speaking persons, the prevalence of depressive symptoms is very high, and preventive interventions can reduce depressive symptoms. The next step is to carry out a randomized controlled trial with sufficient statistical power (see Munoz, 1993b, Table 1)
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From page 292... ...
Accordingly, risk factors for the elderly include relationship loss and bereavement, chronic illness and caregiver burden, social isolation, and loss of meaningful social roles. On the other hand, protective factors include social support in a wide variety of forms-family, peers, informal relationships, more formal support groups, responsive health and social services such as respite care, and opportunities for new productive social roles.
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From page 293... ...
Caregivers are more likely than others to experience problems in the areas of social participation and psychological distress. Furthermore, the relationship between the patient and the caregiver, living arrangements, the caregiver's perceived adequacy of social support, and the caregiver's gender are related to the probability of experiencing lower levels of well-being.
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From page 294... ...
In evaluating the intervention, George and Gwyther (1988) explicitly focused only on risk factors; they did not measure psychological well-being as an outcome of their intervention.
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From page 295... ...
Protective factors for the bereaved include emotional and social support, higher levels of social engagement and interaction, formation of meaningful new social roles, as well as the opportunity in mutualhelp groups for the catharsis and interaction that can lead to personal insight. ~Widow-to-Widow: A Mutual Help Program for the Widowed, developed by Silverman (1988)
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From page 296... ...
Presumably, such a mutual support program could also be useful for widowed men. Randomized trials of this form of support would provide information about the range of impact of the program and about subgroups at higher risk who could be more likely to benefit from the intervention, but few have been conducted.
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From page 297... ...
A NEW GENERATION OF DEVELOPMENTAL STUDIES Recently, a new generation of preventive intervention research studies have been designed and supported by federal, state, and private sources. These studies have adhered to high methodological standards and hold great promise for identifying causality and malleability of individual and combined risk factors, demonstrating efficacy and effectiveness of single- or multiple-component interventions, and assessing not only reduction of risk factors but also reduction of incidence of mental disorders.
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From page 298... ...
· There are data that clearly show that preventive interventions can reduce risk factors that are associated with the onset of many mental disorders. However, as yet, there is no evidence that preventive interventions reduce the incidence of mental disorders.
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From page 299... ...
· Many prevention research programs have smear metnooo~og~ca~ complications: difficulty in adhering to a strict randomized controlled trial design; high attrition of participants; lack of documentation of fidelity in delivering the intervention; lack of multiple measures of outcomes from multiple sources; and insufficient long-term follow-up, which can prevent the collection of outcome data on incidence of multiple disorders. · Some prevention programs get scaled up into field trials or quickly become translated into service programs.
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From page 300... ...
Few of these preventive interventions have used diagnostic criteria to ascertain effects on the incidence of the disorder. Nevertheless, there is promise in several components, including early childhood education, parent training, enhancement of social and academic competence, and school curricula promoting consensual norms antithetical to risk behavior for disorder, such as substance use.
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From page 301... ...
Beginning work in the areas of substance abuse and alcohol prevention and in Olweus's program to reduce bullying shows promise. · Even though biological risk factors have a significant role in the onset of mental disorders, there are few prevention programs other than prenatal care and childhood immunizations that address these factors.
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From page 302... ...
(199Oa) A cognitive-behavioral approach to substance abuse prevention: One-year follow-up.
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From page 303... ...
(1992) Social competence promotion with inner-city and suburban young adolescents: Effects on social adjustment and alcohol use.
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From page 304... ...
(1982) Primary prevention during school transitions: Social support and environmental structure.
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From page 305... ...
(1992) School-based substance abuse prevention: A review of the state of the art in curriculum, 198~1990.
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From page 306... ...
(1992) Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention.
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From page 307... ...
(1987) Social networks and social support: A synthesis for health educators.
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From page 308... ...
Effectiveness of a social relations intervention program for aggressive and nonas,Pre~ive rejected children Journal of Consulting and Clinical Psychology.
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From page 309... ...
(1987) The San Francisco depression prevention research project: A randomized trial with medical outpatients.
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From page 310... ...
American Journal of Community Psychology; 14: 277-289. Penning, M.; Barnes, G
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Journal of Community Psychology; Office of Substance Abuse Prevention Special Issue: 22-38. Rotheram, M
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American Journal of Community Psychology; 13: 111-124. Strayhorn, J
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From page 313... ...
(1979) Identity change over the first two years of bereavement: Social relationships and social support in widowhood.
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